Welcome to:Tools to spark (and teach!) quality improvement in your office!

Disclosure

Simone Dahrouge, PhD, Associate Professor and Scientist, Department of Family Medicine, University of OttawaDr Kheira Jolin-Dahel CCFP, QI Director, Department of Family Medicine, University of Ottawa

We do not have any conflict of interests to disclose and we are not affiliated with any commercial entities or organizations that serve to profit from this presentation. This program has received financial support from the Department of Family Medicine, University of Ottawa.

Workshop Objective

1) Demystifying the steps in QI: – Identify: Identify my clinic’s priority areas for

improvement, – Team: Build my QI team and maintain engagement, – Root: Understand the root of the problem, – Intervention: Identify and select the change best suited

for my practice, – PDSA: Implement the change and monitor improvement

2) Optimizing my learner’s QI experience:– Project: Selecting a meaningful and doable project, – Tools: Providing tools for each step of the QI process, – Template: Following a template process

1. Quadruple aim

Improved patient

experience

Better health

outcomes

Lower healthcare

costs

Improved care team experience

The six dimensions of quality

• Safe• Effective• Patient-Centred

• Timely• Efficient• Equitable

Care Gap in Health Care

• Clinical Audit• EMR data• Surveys• People around us• Patients• Resident projects• Provincial or national initiatives and programs (quality councils, Choosing

Wisely, cancer screening initiatives, etc.) • Surveys• Serious Event Analysis (SEA)• Other..

There are many options to find QI opportunities in health care

Problem/Opportunity Statement

• Step 1: Identifying problem

What I am doing What I want to be doing

Care Gap Analysis

My colleague MeHow

ofte

n w

e ar

e la

te a

t wor

k

GAP

• Specific• Measurable• Attainable/Actionable• Relevant/Realistic• Time-bound

Aim Statement

11

“Some is not a number, soon is not a time.” Donald Berwick

We will reduce/increase/stop/xxx something important and which we can change, by some feasible amount, within some realistic time frame

Tool #1: Project/Improvement Charter

AIM Statement Good Bad Increase use of FOBT kits.Decrease long-term use of benzodiazepines without clear indication by 40% from 5% to 3%.Decrease potentially inappropriate prescriptions (PIPs) from 5% to 3% by December 2019.Don’t prescribe nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.Reduce the long-term use of proton pump inhibitors (PPIs) where indication is lacking from baseline (33%) to 10% by March 2020.Primary physician or team pharmacist perform a medicationreconciliation within two weeks of hospital discharge for all newly discharged patients from 80% to 100% by January 15, 2020.

Are these SMART Aims?

1. Develop a SMART Aims for your improvement idea– One sentence– Consider the SMART elements

2. Review your group’s SMART Aim– Was it SMART?

You have 5 minutes

SMART Aims: Exercise #1

Assemble the Team

• Physicians• Residents• Allied health • Support Staff• Patients • Others

QI requires team work

Tool #2: Team Guide and Template

Level of influence they have? (Low/Med/High)Level of impact this work has on them (Low/Med/High)

Name Representing Influence Impact Role in this project Internal Team Members Other Stakeholders

Understanding the Problem

Analysis Tools

• Process mapping• Swim lane• The 5 WHYs• The 5Ws and 2 Hs • Fishbone diagram• Pareto Chart

START POINT

ACTION STEPS

Direction/Flow

DECISION POINTYes/No

STOP POINT

Elements of a Process Map

https://www.youtube.com/watch?v=F-7cjdtrQ9Y

Being on time at work: Process map

Wakeup

Shower!

Kids awake

?Breakfast Getting

dressed CRISIS

?

Fix crisis

Drop of kid?

Drop kids off

Drive to work

Arrive at work

YESYES

YES

No

No

No

Tool #3: Swim Lanes

Process Mapping: Swim Lanes

Tool #4: 5 WHYs

Tool #5: 5 W 2H

Tool #6:Fishbone Diagram

My Problem

Complete the Fish Diagram provided to you• Consider the various factors that may be

contributing to that problem

You have 5 minutes

Fishbone: Exercise #2

Dress me!

Fishbone DiagramGRAM (ISHIKAWA/ROOT CAUSE ANALYSIS)

Designing the Solution

So what’ya gonnado about it?

Tool #7: Pareto Chart

Change idea Easiest and highest benefit

Change idea

• Make more laundry often• Make my lunch the night before • I will get up earlier• I will go to bed earlier • I will move closer to work • I will get rid of my kids

Not all changes are created equal…

Forcing functions

Automation and computerization

Standardization and protocols

Checklists and double check systems

Rules and policies

Education/information

Reminders “be more vigilant”

BEST

Click to edit Master title styleMeasurements

Processes Outcome

Balance

Use a Family of MeasuresMeasure system performance from different directions/dimensions

Outcomes Measures

• Where are we ultimately trying to go?

• Are your changes leading to improvement

• Measures of the customer or patient• % of patients with

zero unintentional discrepancies / month

• % of adverse drug events/1000 doses

Process Measures

• Are we doing the right things to get there?

• Measures of the workings of the system

• Are we doing the right steps• % of patients

receiving medication reconciliation on admission

Balancing Measures

• Are the changes we are making to one part of the system causing problems in other parts of the system

• Measures of other parts of the system• % of patients who

leave without being seen

Data Collection: Strike a Balance

Source: Adapted from DCFM Curriculum

It’s the new year and I want to get “healthier”; ok I want to lose weight…

I will increase my activity level by going to the gym more often.

Measures: Exercise #3

Propose one measure for each: Process; Outcome; BalancingYou have 5 minutes

PROCESSThe journey

OUTCOMEThe destination

BALANCINGAnd make sure….

Get up early and go to the gym

everyday Get back in shape

… I don’t get to work late!

Click to edit Master title style

Measure Indicator Numerator Denominator Goal

PROCESSGo to the gym

Frequency # days went Period (Week) 4/7

Intensity # hours spent

Period (Week) 6hrs

OUTCOMEFitness Level

Weight control Weight now Weight at baseline (could be diff)

10% or 12 lbs

Muscle building

BALANCINGEffect on life

Late for work # days late Period (Week) 4/7

Unhappy family May not be quantitative

Measures

Tool #7:PDSA

“What will happen if we try something different?”

“Lets try it!”“Did it work?”

“What’s Next?”Act Plan

• Objective• Questions and

predictions• Plan to carry out the

cycle (who, what, where, when)

• Plan for data collection

Study• Complete data analysis

• Compare data to predictions –

update theory• Summarize

what was learned

Do• Carry out the plan• Document problems

and unexpectedobservations

• Begin analysisof the data

• Are we ready to implement?

• Should we try something else?

• Next cycle: Adapt, Adopt, Abandon?

Source: Lloyd, R. & Scoville, R. “The Science of Improvement.” Institute for Healthcare Improvement.

PDSA cycle

Test your change idea – PDSA cycle

Make laundry twice a week Monday and Friday

I did two loads of laundry

It worked well but by Thursday I had no clean clothes left.

I will try doing laundry Monday and Wednesday

Tracking Progress

To change the way you think about data & results!

• Harness the “awesome power of plotting data over time and then intelligently asking questions”

• Understand why Dr. Deming said: “Understanding variation is the key to success in quality”

Click to edit Master title styleQI Toward Optimized Practice

Reduce Variation

Improve performance

Tool #8Run Chart

What Is It?• A run chart is a graphical display of data plotted in chronological order

(over time)• A powerful tool and one of the most useful for understanding and

communicating variation• Easy for team to understand and interpret

When/Why Would I Use It?• Display data to make process performance visible• To determine if a change resulted in improvement• To determine if we are holding the gains made by our improvement

efforts• Answers the question– How will we know that a change is an

improvement?Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title styleAnatomy of a run chart

Median = 37.8

Chronological Order

Mea

sure

Ass

esse

d

At least 10-12 data pointsLine joining values

Direction Desired

Probability Based Rules

FOUR RULES• The four rules have a <5% probability of occurring by

chance• Allow us to determine if the changes made are resulting

in improvement

Source: Murray, S.K. (2010). Data Fundamentals – Using Data to Drive Improvement. A presentation for the Quality Healthcare Network.

Click to edit Master title style

Six or more consecutive POINTS Either all above or all below the median. Skip values on the median and continue counting points. Values on the median DO NOT make or break a shift.

Rule 1 – A Shift

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Mea

sure

or

Cha

ract

eris

tic

Rule 1

Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title styleRule 2 – A Trend

Five points all going up or all going down. If the value of two or more successive points is the same, ignore one of the points when countingLike values do not make or break a trend.

Rule 2

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Mea

sure

or C

hara

cter

istic

Median=11

Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title style

Six or more consecutive POINTS Either all above or all below the median. Skip values on the median and continue counting points. Values on the median DO NOT make or break a shift.

Rule 1 – A Shift

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Mea

sure

or

Cha

ract

eris

tic

Rule 1

Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title style

Too few or too many RunsToo few runs (crossing median) = trend or insufficient data

Add data pointsToo many runs = Different effects occurring

Rule 3 – Runs (Too many or too few)

Rule 3

05

10152025

1 2 3 4 5 6 7 8 9 10

Mea

sure

or C

hara

ceris

tic

Median 11.4

Data line crosses onceToo few runs: total 2 runsData line crosses once

Too few runs: total 2 runs

Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title styleInterpreting outliers

Rule 4: Astronomical Value

Rule 4

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Mea

sure

men

t or C

hara

cter

istic

Source: Provost & Murray (2011). The health care data guide.

Click to edit Master title styleRepeated Use of PDSA Cycles

P

D

S

AP

D

S

A

Click to edit Master title styleGo and Spread Quality